Basic Information
| Provider Information | |||||||||
| NPI: | 1063509271 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COFFEE MEDICAL GROUP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNITED REGIONAL MEDICAL CENTER NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 MCARTHUR DRIVE | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317283586 | ||||||||
| FaxNumber: | 9317230781 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MCARTHUR DRIVE | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317283586 | ||||||||
| FaxNumber: | 9317230781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2006 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOPKINS | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9314613425 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 7440354 | TN | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 445383 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4039933 | 01 | TN | BCBS | OTHER | 0445383 | 05 | TN | MEDICAID | 7440354 | 05 | TN | MEDICAID |